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Addressing the health workforce challenges of the 21st century

Lack of appropriate health workers is a major reason why health services are not reaching poor people in low income countries. Fifty seven countries – mostly in sub-Saharan Africa – do not have the minimum health workforce numbers proposed by the World Health Organization (WHO). In the least developed countries only 35 per cent of pregnant women have access to skilled birth attendance.

How did things get so bad?

Reasons include expanding demand for health services, failing economics leading to reduced public services, piecemeal approaches to addressing health workforce problems and, in general, a lack of appreciation of the changing and globalising labour market in health.

The health workforce was low on the agenda for ministries of health and donors alike, partly because the problems seemed unsolvable. The good news is this is changing. The recognition of the impact of migration and the massive funding increases for HIV and AIDS, tuberculosis and malaria programmes highlights the imperative to address health workforce problems.

Advocacy through the Joint Learning Initiative, the World Health Report 2006 and, as featured in an article here, the Global Health Workforce Alliance, has finally given the health workforce its rightful place on the wider health agenda. Donors are now much more open to funding workforce-strengthening initiatives and even topping up salaries. This issue of Health Exchange provides an excellent range of examples of what can be done when there is a will to address health workforce challenges.

The shortage of health workers – particularly in remote rural areas – is a high profile problem. In some countries, like Malawi, the problem starts with lack of suitably qualified (particularly in science subjects) school leavers to train to be health professionals. Even if there are enough applicants, the lack of training facilities may cause a bottleneck. The buildings may be there, but as the article on pharmacy schools in Africa shows, the teachers may not.
Low training output of new health professionals is supplemented by many countries – not just in the North – by international recruitment – often of volunteers. The Director of the Royal College of Nursing in the UK explains how nurses from the North are working in low income countries with health workforce shortages.

In a rapidly changing labour market, health workers now make choices about what work they want to do, for whom and where. This is why it is so important to understand the job preferences of young graduates, as described in the article on research being carried out in Thailand, Kenya and South Africa. The report from Liberia highlights the challenge of attracting health workers to rural areas.

Faith-based organisations make a major contribution to health service provision – particularly in Africa. The article from the National Catholic Health Service in Ghana explains how they commissioned a study and have developed their retention strategies, which include bonding for training, improving job security and financial allowances, to address the findings. The article from Lesotho’s Christian Health Association (online only) reports on similar experience.

Increased workload, related to both staff shortages and treatment of highly infectious diseases, is having a serious impact on the health of remaining staff, leading to sickness and often to resignation. The International Council of Nurses explains why carers need to be cared for and the dramatic impact this can have on staff retention.

Many health workers decide to take their skills to another country where working conditions and pay are better. Such losses to the country of origin have a serious impact on health services and a raft of strategies to manage migration has been introduced. The most notable is the WHO Code of Practice on the International Recruitment of Health Personnel, still in draft. Earlier drafts and similar codes have stressed that in addition to curbing indiscriminate international recruitment, countries should do more to retain their health workers. The article about managing migration of pharmacists (an interesting group, as we usually only hear about doctors and nurses and often assume the private sector is covering the issue) describes the need for a comprehensive package of retention strategies.

Developing strategies to retain health workers or plan for appropriate numbers requires both human resource planning and management expertise, and appropriate tools. A number of workforce planning tools have been developed, but the Workforce Indicators of Staffing Need (WISN) –developed over a decade ago is a tool that promotes a bottom-up planning process.

Re-thinking who does what is an important part of workforce planning. Recently there has been much emphasis on task-shifting and using non-formal health workers to improve access to health care, as explained in the paper on the role of lay health workers.
Information about what works or does not work, need to be communicated. The PAHO observatory is an excellent example of a process to monitor and share knowledge, to help managers develop more appropriate strategies to meet the workforce challenges.

Shortages of health workers are indeed a problem, but the importance of helping health workers to provide quality services efficiently cannot be over-emphasised. It is notable that the first decade of the 21st century has seen recognition of the need to address health workforce problems seriously. The following pages will provide the reader with some examples of what is actually being done.